趙曼，徐予，朱中玉，安松濤，趙先鋒，陳芳

（河南省人民醫(yī)院心內(nèi)科，河南 鄭州 450000）

18FDG和99mTc-MIBI雙核素心肌顯像對(duì)冠狀動(dòng)脈閉塞性缺血性心肌病治療的臨床價(jià)值

趙曼，徐予，朱中玉，安松濤，趙先鋒，陳芳

（河南省人民醫(yī)院心內(nèi)科，河南 鄭州 450000）

目的對(duì)單支或多支冠狀動(dòng)脈完全閉塞性缺血性心肌病患者，進(jìn)行99mTc-mibi/18F-FDG雙核素心肌斷層顯像檢測(cè)，以評(píng)價(jià)其對(duì)藥物治療或經(jīng)皮冠狀動(dòng)脈介入治療（PCI）術(shù)治療冠狀動(dòng)脈閉塞性缺血性心肌病預(yù)測(cè)價(jià)值。方法139例冠狀動(dòng)脈造影證實(shí)為單支或多支冠狀動(dòng)脈完全閉塞缺血性心肌病患者行18F-FDG/99mTc-MIBI雙核素心肌斷層顯像，根據(jù)其結(jié)果分為有存活心肌組及無(wú)存活心肌組。2組分別根據(jù)是否進(jìn)行PCI治療再分為2個(gè)亞組：PCI+優(yōu)化藥物治療亞組和優(yōu)化藥物治療亞組，治療12個(gè)月。以治療前、后超聲左室射血分?jǐn)?shù)（LVEF）、血漿NT-B型腦鈉肽前體（NT-proBNP）水平評(píng)價(jià)治療療效。結(jié)果存活心肌組接受PCI+優(yōu)化藥物治療亞組54例，優(yōu)化藥物治療亞組24例。治療前LVEF、NT-proBNP水平差異無(wú)統(tǒng)計(jì)學(xué)意義。與治療前比較，兩亞組治療后LVEF均有增加，血NT-proBNP水平均顯著下降，差異有統(tǒng)計(jì)學(xué)意義。但PCI+優(yōu)化藥物治療組LVEF、NT-proBNP水平均較優(yōu)化藥物治療組進(jìn)一步改善，差異有統(tǒng)計(jì)學(xué)意義。無(wú)存活心肌組中PCI+優(yōu)化藥物治療亞組27例，優(yōu)化藥物治療亞組34例。與治療前比較，兩亞組治療后LVEF、血NT-proBNP之間差異均無(wú)統(tǒng)計(jì)學(xué)意義；兩亞組治療后比較，差異無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論藥物治療或PCI術(shù)治療僅對(duì)經(jīng)雙核素心肌斷層顯像證實(shí)有存活心肌的冠狀動(dòng)脈閉塞性缺血性心肌病患者有顯著療效。

雙核素心肌灌注/代謝顯像技術(shù)；經(jīng)皮冠狀動(dòng)脈支架術(shù)；左心室射血分?jǐn)?shù)；存活心肌；NT-proBNP

對(duì)冠狀動(dòng)脈閉塞性缺血性心肌病患者經(jīng)皮冠狀動(dòng)脈介入治療（percutaneous coronary intervention，PCI），仍有1/4～1/3的病例心功能和預(yù)后沒(méi)有得到改善，但其部分病例僅經(jīng)藥物優(yōu)化治療，心功能卻比較穩(wěn)定，甚至得到一定程度的改善[1]。已有研究表明，藥物治療或PCI術(shù)治療后心功能改善均與冠狀動(dòng)脈閉塞相應(yīng)心室壁內(nèi)是否有存活心肌有關(guān)[2-7]，目前國(guó)內(nèi)相關(guān)報(bào)道甚少。本文對(duì)經(jīng)冠狀動(dòng)脈造影（coronary angiography，CAG）證實(shí)為單支或多支冠狀動(dòng)脈完全閉塞性缺血性心肌病患者，進(jìn)行99mTc-mibi/18F-FDG雙核素心肌斷層顯像（dual imaging using isotope stimultaneous acquisition，DISA）檢測(cè)，以評(píng)價(jià)其對(duì)藥物治療或PCI治療術(shù)治療冠狀動(dòng)脈閉塞性缺血性心肌病預(yù)測(cè)價(jià)值。

1 資料與方法

1.1 研究對(duì)象

選取2011年8月-2014年1月在河南省人民醫(yī)院經(jīng)CAG結(jié)果證實(shí)為單支或多支冠狀動(dòng)脈完全閉塞缺血性心肌病患者139例。入選標(biāo)準(zhǔn)：①至少一支冠狀動(dòng)脈完全閉塞，冠狀動(dòng)脈遠(yuǎn)端血流TIMI 0級(jí)；②心功能不全（NYHA分級(jí)Ⅱ～Ⅲ級(jí)）；③超聲心動(dòng)圖顯示左室舒末內(nèi)徑女性＞50 mm，男性＞55 mm，LVEF＜45%。排除標(biāo)準(zhǔn)：①急性ST段抬高型心肌梗死；②合并嚴(yán)重肺或腎臟疾?。虎蹏?yán)重心臟瓣膜疾??；④6個(gè)月內(nèi)腦血管疾病史。

1.2 研究方法

1.2.199mTc-MIBI/FDG雙核素SPECT心肌顯像所有患者檢查日均晨起禁食，靜脈注射99mTc-MIBI 740～1 110 MBq，20 min后進(jìn)脂餐，30 min后測(cè)定患者的血糖濃度，將血糖濃度控制在7.9～8.8 mmol/L之間。如果患者血糖濃度低于7.8 mmol/L，則口服葡萄糖補(bǔ)充；如果血糖濃度高于8.9 mmol/L，則需要皮下注射胰島素降低血糖濃度。在血糖控制10～15 min后，靜脈注射18F-FDG 185～370 MBq，1 h后行DISA顯像。獲得短軸、垂直長(zhǎng)軸、水平長(zhǎng)軸的心肌灌注及心肌代謝對(duì)照?qǐng)D像。由2位以上醫(yī)師盲法對(duì)灌注及代謝圖像進(jìn)行評(píng)價(jià)。灌注圖像評(píng)分標(biāo)準(zhǔn)分為5級(jí)，分別為：正常；放射性分布輕度減低；中度減少；明顯減低；放射性分布缺損。以放射性分布缺損存在是否分為相應(yīng)閉塞血管心肌存活組和無(wú)心肌存活組。

1.2.2 病例分組與治療所有患者均行優(yōu)化藥物治療，如ACEI類藥物、β受體阻滯劑、螺內(nèi)酯、他汀類藥物、阿司匹林腸溶片等，必要時(shí)加服地高辛等。2組分別根據(jù)是否進(jìn)行PCI治療再分為2個(gè)亞組：PCI+優(yōu)化藥物治療亞組和優(yōu)化藥物治療亞組。PCI+優(yōu)化藥物治療組行相應(yīng)閉塞血管PCI治療，PCI術(shù)后TIMI血流均達(dá)Ⅲ級(jí)。治療后1、3、6和12個(gè)月定期門診隨訪，觀察12個(gè)月。

1.2.3 超聲心功能及NT-proBNP測(cè)定入組前和治療12個(gè)月分別進(jìn)行常規(guī)心臟超聲心動(dòng)圖（ultrasonic cardiography，UCG）及NT-proBNP檢測(cè)。在左側(cè)臥位下，應(yīng)用彩色超聲檢測(cè)儀（飛利浦IE33）經(jīng)胸行心臟彩超檢查，超聲二維左室長(zhǎng)軸切面檢測(cè)左室舒張末內(nèi)徑（LVEDD）和左室收縮末內(nèi)徑（LVESD），左室射血分?jǐn)?shù)（left ventricular ejection fraction，LVEF），取5個(gè)心動(dòng)周期均值。經(jīng)肘靜脈采血，靜脈血注入預(yù)先加入乙二胺四乙酸（EDTA）的試管中，應(yīng)用羅氏Cobas E601診斷儀檢測(cè)NT-proBNP。

1.3 統(tǒng)計(jì)學(xué)方法

采用SPSS 16.0統(tǒng)計(jì)軟件進(jìn)行數(shù)據(jù)分析，計(jì)量資料用均數(shù)±標(biāo)準(zhǔn)差（±s）表示，心肌存活組及無(wú)心肌存活組包括LVEF、NT-proBNP比較用t檢驗(yàn)，P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 心肌存活組和無(wú)心肌存活組一般臨床資料

心肌存活組78例，非心肌存活組61例，兩組除PCI手術(shù)比例有明顯差異外，其他各指標(biāo)之間差異均無(wú)統(tǒng)計(jì)學(xué)意義（P＞0.05），見(jiàn)表1。

表1 心肌存活組和非心肌存活組治療前一般臨床資料例（%）

2.2 存活心肌組PCI+優(yōu)化藥物治療與優(yōu)化藥物治療療效比較

存活心肌組中接受PCI+優(yōu)化藥物治療亞組54例、優(yōu)化藥物治療亞組24例。兩個(gè)亞組心血管危險(xiǎn)因素和冠狀動(dòng)脈病變無(wú)明顯差異（P＞0.05），比較治療前LVEF、NT-proBNP水平，差異均無(wú)統(tǒng)計(jì)學(xué)意義。2個(gè)亞組隨訪12個(gè)月后，與治療前比較，LVEF均有增加，血NT-proBNP水平均顯著下降，差異有統(tǒng)計(jì)學(xué)意義。但治療后12個(gè)月后，PCI+優(yōu)化藥物治療組LVEF、NT-proBNP水平均較優(yōu)化藥物治療組進(jìn)一步改善，差異有統(tǒng)計(jì)學(xué)意義（P＜0.05），見(jiàn)表2。

表2 存活心肌組PCI+優(yōu)化藥物治療與優(yōu)化藥物治療療效比較（±s）

表2 存活心肌組PCI+優(yōu)化藥物治療與優(yōu)化藥物治療療效比較（±s）

注：1）與治療12個(gè)月后2組比較，P=0.038；2）與治療組比較，P=0.003

LVEF/%NT-proBNP/（ng/L）治療前治療12個(gè)月治療前治療12個(gè)月P值PCI術(shù)+優(yōu)化藥物治療（n=54）40.16±6.0243.16±5.241）0.0234 586.48±514.62421.34±92.052）0.001優(yōu)化藥物治療（n=24）40.08±5.3642.97±5.480.0314 492±483.591015±95.120.001組別P值

2.3 無(wú)存活心肌組PCI+優(yōu)化藥物治療與優(yōu)化藥物治療療效比較

無(wú)存活心肌組中PCI+優(yōu)化藥物治療亞組27例、優(yōu)化藥物治療亞組34例。與治療前比較，2個(gè)亞組隨訪12個(gè)月后LVEF、血NT-proBNP差異均無(wú)統(tǒng)計(jì)學(xué)意義；2個(gè)亞組治療后比較，差異亦無(wú)統(tǒng)計(jì)學(xué)意義，見(jiàn)表3。

表3 無(wú)存活心肌組PCI+優(yōu)化藥物治療與優(yōu)化藥物治療療效比較（±s）

表3 無(wú)存活心肌組PCI+優(yōu)化藥物治療與優(yōu)化藥物治療療效比較（±s）

LVEF/%NT-proBNP/（ng/L）基線（CAG術(shù)前）基線（CAG術(shù)前）12個(gè)月PCI術(shù)+優(yōu)化藥物治療（n=27）40.05±3.3641.28±4.054 387.68±357.924 054.32±189.65優(yōu)化藥物治療（n=34）40.11±6.0241.16±5.654 693.24±93.814 427.53±82.69組別12個(gè)月

3 討論

99mTc-MIBI/18F-FDG雙核素同步心肌顯像可同時(shí)獲得心肌血流灌注及代謝圖像，可較準(zhǔn)確地估價(jià)心肌灌注及代謝水平，判斷存活心肌的部位及范圍，克服單純應(yīng)用FDG顯像無(wú)法區(qū)分正常和缺血心肌的局限性。其他學(xué)者應(yīng)用99mTc/18F-FDG雙核素同步心肌顯像檢測(cè)存活心肌，證明DISA法SPECT顯像對(duì)檢測(cè)心肌存活性有重要價(jià)值，能有效地識(shí)別存活心肌且方法簡(jiǎn)便[5]。國(guó)外進(jìn)一步相關(guān)研究亦說(shuō)明雙核素心肌顯像可以無(wú)創(chuàng)、快捷而又準(zhǔn)確地觀察PCI后心肌的灌注及代謝變化[8-12]。

本研究結(jié)果顯示，單支或多支冠狀動(dòng)脈完全閉塞的缺血性心肌病患者中，經(jīng)18F-FDG/99mTc-MIBI雙核素心肌斷層顯像檢測(cè)，證實(shí)僅有存活心肌的患者接受PCI+優(yōu)化藥物治療或單純優(yōu)化藥物治療，均可顯著提高LVEF、降低血NT-proBNP水平，且聯(lián)合治療療效進(jìn)一步提高；反之，PCI+優(yōu)化藥物治療或單純優(yōu)化藥物治療對(duì)無(wú)存活心肌的患者，上述心功能指標(biāo)均無(wú)顯著性改善。本研究結(jié)果提示，對(duì)單支或多支冠狀動(dòng)脈完全閉塞的缺血性心肌病患者，應(yīng)進(jìn)行雙核素心肌斷層顯像檢測(cè)評(píng)估存活心肌；對(duì)有存活心肌的患者推薦PCI+優(yōu)化藥物治療，對(duì)無(wú)存活心肌的患者，基于PCI+優(yōu)化藥物治療效果比較差異無(wú)統(tǒng)計(jì)學(xué)意義，僅推薦優(yōu)化藥物治療。本研究支持近期國(guó)外研究結(jié)果，VAN等[13]研究證實(shí)，僅具有存活心肌的患者經(jīng)血運(yùn)重建后LVEF值明顯提高，而無(wú)心肌存活患者雖經(jīng)血運(yùn)重建，LVEF卻無(wú)明顯改善。COURAGE核素亞組研究[14]中，105例輕度缺血的患者在隨訪1年后再次接受核素檢查，結(jié)果顯示PCI+藥物治療組較單獨(dú)優(yōu)化藥物治療組有更多的顯著缺血降低。隨后COURAGE核素亞組對(duì)心肌灌注顯像中度以上缺血的468例患者的分析顯示與單獨(dú)藥物治療相比，PCI+藥物治療組并未降低死亡[15]。另外，國(guó)外已有研究顯示冠心病患者存活心肌數(shù)量越多，心功能改善越顯著，反之亦然[16-18]。

本研究結(jié)果有一定的局限性，入選病例數(shù)偏少，觀察時(shí)間僅限12個(gè)月，故需要大樣本的多中心研究、且更長(zhǎng)時(shí)間隨訪進(jìn)一步證實(shí)。

總之，合理應(yīng)用雙核素心肌顯像不僅可以指導(dǎo)患者治療方案，而且可以節(jié)約大量醫(yī)療費(fèi)用，這在我國(guó)目前情況下尤為迫切和必要。

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（張蕾 編輯）

Predictive value of radionuclide myocardial perfusion/ metabolic imaging technology(99mTc-MIBI/18F-fluorodeoxyglucose)in treatment for coronary artery occlusive ischemic cardiomyopathy

Man ZHAO,Yu XU,Zhong-yu ZHU,Song-tao AN,Xian-feng ZHAO,Fang CHEN
(Department of Cardiology,Henan Provincial People's Hospital,Zhengzhou, Henan 450000,P.R.China)

【Objective】To evaluate the predictive value of radionuclide myocardial perfusion/metabolic imaging technology[99mTc-MIBI/18F-fluorodeoxyglucose(18F-FDG)]in the treatment for coronary artery occlusive ischemic cardiomyopathy.【Methods】Totally 139 patients with ischemic cardiomyopathy associated with single or multiple coronary artery occlusion confirmed by coronary artery angiography were enrolled in this study.These patients were divided into survival myocardium and non-survival myocardium groups according to the99mTc-MIBI/18F-FDG dual isotope SPECT myocardial imaging.According to whether receiving percutaneous coronary intervention(PCI)treatment,both groups were further divided into two subgroups:PCI+optimal medical therapy and simple optimal medical therapy subgroups.The course of treatment lasted for 12 months.Left ventricular ejection fraction(LVEF)and plasma level of N-terminal probrain natriuretic peptide(NT-proBNP)before and after treatment were used to evaluate the treatment efficacy.【Results】In the survival myocardium group,LVEF was increased and the NT-proBNP level decreasedsignificantly after treatment in both subgroups.However,compared with the patients only receiving optimal medical therapy,LVEF and NT-proBNP level were further significantly improved after treatment in the patients receiving optimal medical therapy combined with PCI.In the non-survival myocardium group,no significant difference was found in LVEF or NT-proBNP level in both subgroups after treatment compared to thatbeforetreatment,therewasnosignificantdifferencebetweenbothsubgroupsaftertreatment.【Conclusions】DrugtreatmentorPCItreatmentisobviouslyeffectiveonlyforthesubjectswiththe myocardial viability among the patients with ischemic cardiomyopathy associated with single or multiple coronary artery occlusion.

radionuclide myocardial perfusion/metabolic imaging examination；PCI；left ventricular ejection fraction；viable myocardium；N-terminal pro-brain natriuretic peptide

R541.4

B

1005-8982（2015）30-0053-04

2015-06-14